Medicine/
Public health
Arutiounov
Yuri Artemovich
Clinical-diagnostic
Center of the First Moscow Medical University
Cardiovascular diseases risk management: outpatient
setting algorithm
Cardiovascular
diseases (CVD) is a large group of serious socially-significant ones. Among
them miocardial infarction and stroke are the main problems in USA, Russia and
Europe [3].
CVD
risk management is a cyclic work of medical team. It consists of therapist (personal treating doctor), nurse and
doctors-consultants. In Russia we have a grate deficit of nurses in outpatient
settings. In the case of risk realization doctors haven't official
recommendation.
Existing
dispanserisation system is a Russia's phenomenon of preventive activity on the
population level. It is aimed to prevent fatal CVD and accompanying diseases,
prevent invalidity.
Dispanserisation
helps to fill the gap between clinical guidance and real clinical practice. In
outpatient settings life style strategies will be more effective in patients of
high and very high fatal CVD risk than in patients of low and intermediate
risk.
In
the CDC of the First Moscow State Medical University risk management algorithm
was established on the dispanserisation base. It contains two moduls: CVD
preventive activity and activity in the case of CVD risk realization.
CVD
preventive activity in our outpatient setting can be divided into four steps.
1
A. Therapist interprets patient's medical narrative, constructive analyzes of
complaints, concludes informed consent, develops the plan of treatment and
researches. What technical means cannot
replace alive human dialogue and trust [1].
1
B. Consultants help with verification
diagnosis: ophthalmologist investigates eye fund, gynecologist
recommends medications if climax syndrome, neurologist treats dizziness,
andrologist corrects erectile dysfunction, endocrinologist help to treat
metabolic syndrome, cardiologist makes treadmill test.
1
С. Laboratory
analyzes: HDLP-cholesterol, LDLP-cholesterol, Triglycerides, Total Cholesterol,
Transaminases, Glucose.
1
D. Instrumental researches: ECG, Echocardiography, bi-functional ECG and blood
pressure monitoring.
2 A.
Therapist estimates initial CVD risk with
European SCORE scale, recommends three-component preventive medicines, life
style change. Today it is known from evidence-based medicine that
anti-hypertensive, beta-blockers, anti-hyperlpidemic and acetylsalicylic acid
prolong a life.
2
B. Psychotherapist recommend self-help. Peseschkian have proved that the most
of CVD are psychosomatic diseases and will give in to treatment by the
corporal-oriented methods of psychotherapy [2].
3.Therapist
and a nurse control drug therapy by phone, e-mail, SMS.
4.
Therapist estimates final risk and
if necessary change the diagnosis and tactics of treatment.
This cycle repeats till the realization of
the risk. Then medical team must work as follow:
A.
Therapist apologizes, simpatizes, explains defects
of sheduled medical aid (if they occurred).
B.
If patient is non-satisfied, medical team’s leader apologizes, simpatizes, explains defects
of sheduled medical aid (if they occurred).
C.
If patient is non-satisfied yet, the administrator in writing assures the
patient that medical team worked in conformity with standards. If defects
have been admitted, administrator assures that
guilty will discharged of work, will be directed on additional training.
D.
If the patient brings an action ad win it, the outpatient setting
administration pays the patient indemnification. For decrease
in financial risks the insurance of professional responsibility of doctors in
this case it is expedient. In the further patient continues preventive
treatment (see CVD preventive activity algorithm).
For
stable functioning system of CVD risk management it is necessary to spend monitoring
of the critical control points.
1-3
steps. The doctor have a holistic image of his patient and can advocate his
patient's rights, correctly write ambulatory card, the presence of signed
informed consent in the card.
4.
Reliability of distinction between initial and final CVD risk estimation
is the
main aim. The intermediate purposes the following: achievement of target
levels of HDLP-cholesterol,
LDLP-cholesterol, Triglycerides, Transaminases, Glucose
In
the Clinical – diagnostic Center of the First Moscow State Medical University
was established such CVD risk management system. We selected 108 ambulatory
cards of patients with iscemic heart disease and arterial hypertension. They
where supervised by their doctors 3-5 years.
Control group consisted of 83 patients. They didn't conclude informed
consent to dispanserisation. Average возраст in supervised
and control group were 55,2±7,5 years old and
57,5±5,5 years old соответственно. Female were 60,5% in supervised group and 58,0% in control one. We used метод непрямых разностей с учетом доверительного интервала. In the supervised group there were more patient of intermediate CVD
risk: 55 vs 17 (p≤0,05), less patients of the very high risk: 5 vs 10 (p≤0,05), less patient
of high risk: 20 vs 30 (p≤0,05). As the result of preventive activity patients transit from high
and very high risk group into intermediate one more in the supervised group: 15
vs 3 (p≤0,05).
In conclusion we can resume that in the light of
National project “The Health” dispanserisation of patients with CVD is
considered as the cornerstone of Russia's healthcare system again.
Literature:
1.
Дернер К. Хороший врач. Учебник основной позиции врача. -
М.: Алтейя, 2006 — 470 с.
2.
Пезешкиан Н. Психосоматика и позитивная психотерапия. Межкульттурные
и междисциплинарные аспекты на примере 40 историй болезней. - М.: Институт
позитивной психотерапии, 2006 — 254 с.
3.
www. gks.ru